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Anji is a club runner for Tyne Bridge Harriers who has very kindly agreed to share her injury story with us. What shines through is her determination, positive attitude and commitment to staying fit, which she did largely through aqua training. For more information on this, visit Anji's blog where she has details of training and videos of deep water running. Now it's over to Anji…

When I signed to my club Tyne Bridge Harriers in January this year, I had no idea how my first year in my black and white vest would pan out. I raced as a TBH only 4 times before being struck down with a serious injury, and at time of writing I haven’t run in almost 4 months. Here is my journey.

After recovering from a stress fracture (left cuboid) in early 2011, running became my life. I had been out for 10 weeks and during that time I swam twice every day, read nothing but training plans and came back knowing that I just couldn’t be without running in my life. I completed my first half marathon in September 2011 and became addicted to the buzz of racing, but often carried niggles particularly in my feet and ankles. I ran with the motto “Determination Is Everything” and never let myself feel beaten. At the end of 2011 I had set a new 10kpb by over 4 minutes as well as running my first 5mile race and my first multi-terrain 10k.

Signing to Tyne Bridge gave me more confidence and joy in my running than I had ever had before, and I’m first to admit this new vigour led me to massively increase my mileage to feed my addiction. I had entered masses of races and felt I really wanted to prove myself in the ladies team. New pain in my right foot leading into my first ever relay race in February 2012 led me to run awkwardly and during training in early March, I found myself with new severe pain in the left. I stopped running for a week or so and saw physio who diagnosed a ligament sprain in early April following an incredibly painful 10k and a niggly half marathon all in the same week. Looking back, I did everything wrong. At the end of that 10k I couldn’t walk at all and I knew something was seriously wrong. Again, I took a couple of weeks off running and returned with hope that I would make it back for my race of the year, the Manchester 10k which I was running with my coach pacing me for what would hopefully be my first sub-45.

My few runs in the interim were niggly and ended in loads of pain again, and my frustrations led my GP into recommending I had an MRI scan. The scan results came back on May 15th(the week of Manchester) and confirmed that I had two acute stress fractures in my left heel as well as evidence of a healing fracture in the fourth metatarsal on my right foot. I was devastated. I just had no idea how I was going to cope with a long period out again. The MRI images were sickening and I spent quite a long time over the following weeks just looking at them in disbelief.

I saw three orthopaedic specialists in that first week and all of them thankfully agreed that I wouldn’t need to wear a cast. Instead I was given crutches and a walking cast “moon boot” and ordered that I couldn’t weight bear or even cycle for the first month. Heel fractures are treated like an egg shell where one crack can lead to another and they told me this could go on for up to 12 weeks. The first weekend I was in the boot I travelled to Manchester as my accommodation was already paid for and I was determined to still be there for my coach who was now going to run it sub-45 just for me. I had an extremely emotional day but I managed to meet one of my running heroes Nell McAndrew who was wonderful and very supportive about my injuries.

Week 1

What happened next was a true cruel twist of fate that was to shape my rehab and recovery over the following few months. My coach and running buddy Rob came through the finish looking laboured and in pain, went missing for ages in the medical tent area and eventually came through in sheer agony. It is still hard to believe but the following day back at home, Rob was diagnosed with an acute stress fracture in the same foot as me. Now if you’re going to be injured with anyone, best be someone who already knows all of your moans and demands in training. Together we researched rehab options and following a few recommendations from people at the club, embarked on an aqua running programme. I had recently passed my Leadership in Running UKA qualification and decided to have a go myself at adapting an aqua running plan I had found online, as well as seeking advice from marathoner Aly Dixon who had previously been out for a long period with fractures in her foot and remained strong by using pool work. The plan was epic and included “long runs”, pace work, interval sessions, pyramid sessions and daily swimming or gym work focusing on upper body or core. The sessions were designed to mimic what you would do on the road as well as raising heart rate and keeping the legs strong. Deep water running using a floatation belt is often used by athletes when injured or for cross training, and at that stage it really was our only choice.

Week 6

I’d be happy to share the plan I created with anyone reading this, but there are several good ones online worth looking at if you are going to be out for a while. My plan comes with something of a health warning. An example week would look like this:

NB: All sessions include at least 5min warm up and cool down of steady steps.

‘Hard’ is aiming to get to high cadence of 180steps per minute.

The plan was progressive and led into sessions of almost 70mins with 60 at high cadence.

Aqua running became our new addiction and the burn in the quads as well as weekly photographs of my legs (!) showed us that it was working. The high cadence of 180 was initially a challenge but once it clicks it becomes natural and we now regularly finish the sessions with a minute “race” in which my PB is 227 steps with Rob’s at an epic 241!

Now I’m not going to lie to you and say that it has been easy. Aqua running can be soul destroying. Its tiring, the constant cycle of getting in and out of the pool (some days twice) 6 days a week with a very uncomfortable belt on has led to several quite explosive arguments between Rob and I, I have cried in the pool and on two occasions I have got out, taken the belt off and said “I cannot do this today”. It’s hard to keep focused sometimes when you have no way of really knowing if what you are focusing all of your energy, time and often money into is actually even working. But we supported each other and as we are coming to the end of the 9 week programme, we agree we are glad we’ve done this together.When we finish the plan this week we will have done 48 aqua running sessions and only one of those was apart.

Now the big question. DOES IT WORK?

Following a few setbacks, I am still partly using crutches and not cleared to run. My heel still swells every day and can be painful to walk on. I can cycle and I’m beginning to use the cross trainer, and I know that I’m nearly at the end of this awful time. Rob however is a different story. His fracture is almost fully healed and he is running a few times a week now, and FAST. Rob tells me the high cadence his legs are used to in the pool has translated now to the road and this style along with how strong his legs are now has led to fast miles and in his first race back, a 2mile handicap race at our club he recorded a new PB of 12:16. He inspires me all the time and keeps me believing that I will come back stronger and faster.

Anji and Rob

It’s 16 weeks today since that 10k which I finished unable to walk and for almost 11 of those weeks I have been on crutches. It has been one of the worst periods of my life and at times I have thought frequently that I will have to give up on the only thing I have ever really loved. I have taken myself away from the running world a few times and I have shut people out who I felt wouldn’t understand. I absolutely can’t wait to run again. I have ended up missing Sunderland 10k, Manchester 10k, Potters Half Marathon, Bridges of the Tyne 5 mile road race and the Great North 10k, and I’m slowly making peace with the fact that I probably won’t be ready for my beloved Great North Run on September 16th. I have remained an active part of my club, working for our Twitter page@tynebrharriers as well as working on registration and results for our inaugural road race at the start of July. I also recently worked as a marshal for Great Run and the GN10k in Gateshead. It can be emotional knowing I was meant to run, but the rewards have been immense. Whilst injured I have met Nell, Aly Dixon, Steve Cram, Sally Gunnell, Gemma Steel and Scott Overall, all through being part of races I was meant to run in, and all of them have signed my unused numbers so that I wouldn’t be tempted to burn them in a fit of frustration.I would urge people with long-term serious injuries to remain involved in racing wherever they can.

I really believe in the phrase “Run the mile you’re in” and not to look back or forward. It just so happens that this particular mile has been long, painful and frustrating. But it won’t be long now, and I just can’t wait.

Determination Is Everything.

You can follow Anji on Twitter; @enigmagirl81. Tyne Bridge Harriers are based in the East End of Newcastle, if you fancy joining them, you can do here.

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Shin pain often gets described as the dreaded “Shin Splints”, the bane of many runners and an ongoing topic of discussion on the RW forums. The thing is shin splints isn’t really a diagnosis, it’s a collection of several potential diagnoses. Shin pain can be divided into 4 broad categories, bony, muscular, vascular and neural pain. As this is a complex area I’ve spread it across three blogs. In Part One we’ll look at bony pain and “shin splints”, Part Two compartment syndrome and Part Three tendonopathy and the rarer stuff – vascular and neural.

Bony Pain

The surface of bone is covered in a layer called periosteum (see picture below, this link has details on ankle anatomy and terms like “medial” and “lateral”). This layer has a good blood and nerve supply – as a result it’s very capable of creating pain. Bone tends to respond to stress by strengthening, but, as you see from the diagram below, if the stress on the bone is too great then a “stress reaction” occurs. If this process continues without the bone having adequate rest to strengthen then a stress fracture can occur. There appear to be 3 stages to the development of a stress fracture;

Bone marrow oedema

Inflammation of the periosteum

Stress fracture.

The early stages of this can be pain free. In fact some research has found stress fractures with no symptoms that then resolved spontaneously without intervention. During the second stage where the periosteum of the bone is inflamed, a diffuse (spread out) pain is often described. Sometimes runners find this is present at the start of a run but reduces as they continue. If this progresses to an actual stress fracture a more focal, more specific pain is expected. Usually this gets progressively worse when running, forcing a runner to stop.

Picture from Ruohola 2007

The medial border of the tibia (on the inside) is a common area for stress fractures. They can also occur in the fibula and the anterior part of the tibia (the front of the shin) although this is more rare.

A medial tibial stress fracture is a non-critical stress fracture, this means it usually heals well as it has a good blood supply. It normally takes 4-8 weeks for symptoms to settle enough to start a gradual return to running but on average 8-12 weeks for full return to sport.

An anterior tibial stress fracture is a bit more complex and comes under a the “critical” banner. This means it takes longer to heal and has more complications. However people can often return to running after around 4-6 months depending on how well they heal.

Symptoms of a stress fracture include pain on palpating the bone (feeling along the length of the bone) and pain on any impact. You may also have swelling or bruising over the fracture site. The problem is it’s quite hard to diagnose a stress fracture without any scans/ X-rays. It’s a bit more straight forward to rule one out. If you can tolerate impact e.g. Repeated hops are pain free and palpating the bone is not tender, there is a good chance you don’t have a stress fracture. But if impact hurts and there is bony tenderness, that doesn’t mean you definitely have a stress fracture. The only way to tell would be through either an X-ray, MRI or bone scan. X-rays often miss stress fractures and so a second X-ray is done around 4 weeks later and you look for signs of bony healing. Even then it’s easy to miss. MRI or bone scan are better but harder to get on the NHS. This site has some excellent X-ray and scan results for several types of stress fractures, well worth a look. More info on stress fractures here from the American Orthopaedic Society for Sports Medicine.

Medial Tibial Stress Syndrome (MTSS) and Anterior Tibial Periostitis

Just to confuse you (and me) there are several other terms used to describe bony stress reaction. Some people see these as part of the stress reaction spectrum i.e. a stage on the path to stress fracture, and others see them as a separate condition.

MTSS is considered by some to be the medical term for Shin Splints. It refers to diffuse inflammation of the periosteum on the medial part of the tibia. Pain is expected to be diffuse and linear (along the bone) rather than focal (at one particular point). Some have theorised that MTSS occurs as a result of stress caused by the pull of deep fibres of the soleus muscle (in the calf) on the tibia.

Tibial Periostitis is another term for inflammation of the periosteum, when it occurs at the front of the tibia it can be termed Anterior Tibial Periostitis. One of the main muscles in the shin is Tibialis Anerior. It attaches to the front of the tibia. In theory the pull of this muscle on this area can cause the periosteum to become inflamed.

Management of Stress Fractures and Bony Stress Reaction

The first stage is to work out a likely diagnosis. If there is any question of a stress fracture then get it properly assessed! My old favourite if in doubt get it checked out!.

The assessment should then clarify the nature and location of the problem and aid you in managing it. This isn’t something that should be managed solely through advice from this or other sites. As you’ll see above a period of rest is often required to allow the bone to heal. This period is governed by the location and nature of the fracture you have. The help of a health professional is needed to decide how long this rest period should be and what other management is needed. It’s also likely you’ll need an X-ray, MRI or bone scan. The rest period is usually between 4 and 12 weeks but this can vary and will be longer for a “critical” stress fracture (such as the anterior tibia). Medial Tibial Stress Syndrome or Anterior Tibial Periostitis may require less rest but symptoms need to be closely monitored. The causes below are relevant to MTSS as well, as they all aim to address any factors that might place extra stress on the bones in the lower leg.

Use your rest period to help you identify the cause of the problem. This is where Physio can be very helpful. Most often it’s training error – excessive mileage, change in intensity or running surface, but other factors play a part;

Running shoes – Footwear that is too old will lose it’s ability to support your foot. Replace your shoes when you start to feel they have lost their spring or if the sole of the shoe loses it’s rigidity and becomes bendy. There is no definite figure in terms of mileage but a general guide seems to be to replace shoes every 300-500 miles. It depends a lot on you, your running and the shoe you have. Ensure you have the correct running shoe for your foot type, a running gait assessment may help this.

Altered biomechanics – over pronation, high arches and leg length difference have all been connected with stress fractures. Assessment from a podiatrist might help identify and treat these factors.

Poor running form – running form and biomechanics are intimately linked in running. Excessive hip adduction (the hip moving in towards the other leg during running) and over pronation during running have been linked with stress fractures in the research. Poor control of impact on landing could also lead to increased bony stress. Again, having your gait analysed could help identify this but bare in mind a 5 minute jog on a treadmill may not see how your gait changes when you’re fatigued after running a distance.

Poor movement control – again linked with biomechanics, running form and muscle strength, your control of movement will affect how your legs deal with impact. With good movement control the ground reaction force is dissipated throughout the leg (I.e. a number of muscles, tendons, ligaments, bones and joints deal with the impact of running). If movement control is poor this can place greater stress on certain areas. Check your single leg balance and single leg dip and compare left and right. Once you can tolerate impact you can also ask your Physio to assess your impact control – here they will look for excess movement in the ankle, knee, hip or trunk and help identify how to improve your control.

Muscle Tightness – tightness in the calf muscles or tibialis anterior can place increased stress on the tibia during running. Compare your flexibility on each leg. You can then add stretches to your rehab when guided to do so by your health professional. Stretching too early in the recovery process can be painful as it places stress on healing bone.

Ankle Joint range of movement – if your ankle is stiffer on one side this can have an affect on running gait and biomechanics. For example, ankle dorsiflexion (upward movement) is essential during impact, if the ankle is stiff in this movement it often compensates by over pronating. This can increase bone load in the tibia or fibula. One way to test ankle dorsiflexion is the knee to wall test, this is linked to calf muscle tightness as well as joint stiffness. Inward and outward movement of the ankle is also important (inversion and eversion), again compare left and right and work on it to correct the difference.

Muscle Weakness – strong muscles help to absorb the impact involved in running. Those muscles need not only strength, but also the endurance to keep working mile after mile. Look for any areas of muscle weakness in the leg. Compare both sides, check the calf (with repeated single leg calf raises) the quads (repeated single knee dips) the glutes (repeated clam, side lying leg lift, or single leg bridge) and the hamstrings (repeated hamstring curls in standing). You can also compare using weight machines for a more accurate measure.

General Health – in some cases (more commonly in women than men) a runner may have reduced bone density leaving them more at risk of stress fracture. This can occur through changes in diet, with conditions affecting the gut or bowel (e.g. Celiac disease, Crohn’s disease), with prolonged steroid useage and with menstrual irregularities.

Rehab

Rehab following a stress fracture can be a frustrating and slow process. Once you’ve grown to love running it’s very hard to stop doing it! Despite this, it’s vital you listen to your GP/ Physio/ health professional during your rehab. They can guide you in returning to running and when to start strength or flexibility work. You can usually cross train when not running as long as no impact is involved and it remains pain free. Swimming and cycling are commonly recommended, but again be guided by your health professional. I have heard people on forums saying “I’ve been told not to run but….” it’s not worth the risk of running before a fracture is healed – you could face a much longer lay off if you do.